Fill and Sign the Fillable Online Cornea Donation in Denmark Fax Email Print Form

GN -4110, 05/14 Report and Recommendation of Guardian ad Litem (Annual Review of Protective Placement) §55.18(2), W isconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE MATTER OF Name of W ard Amended Report and Recommendation of Guardian ad Litem (Annual Review) Date of Birth Case No. I am the court appointed guardian ad litem for the above -named individual. I certify to the court that I have complied with the requirements of a guardian ad litem under §55.18 (2) (a) to (e), Wis . Stat s., (except as noted in the “Additional Comments” section at the end of this report) and this report is being filed within 30 days of my appointment. 1. I have reviewed the county department’s annual report of the review of the status of the individual, the Annual Report on the Condition of the Ward, and any other relevant reports on the indiv idual’s condition and placement. 2. I have personally met with the individual and contacted the indivi dual’s guardian. 3. I have orally explained to the individual and to the individual’s guardian, and provided to the individual and the individual’s guardian in writing, all of the following: A. The procedure for review of protective placement. B. The right of the individual to counsel, including when a lawyer can be appointed. C. The right to an independent medical or psychological examination on the issue of competency (at county expense if the person is indigent). D. The contents of the county d epartment’s annual report of the review of the status of the individual. E. That a change in or termination of protective placement may be ordered by the court. F. The right to a hearing and an explanation that the individual or the individual’s guardian m ay request a full due process hearing. 4. I have reviewed the individual’s condition, placement, and rights with the individual’s guardian, and I have ascertained whether the individual wishes to exercise any of the individual’s rights. Based on these revie ws, I make the following report: A. Individual’s current living arrangement i s a nursing home . an intermediate facility. a center for developmentally disabled. a CBRF. an adult family home. Other: Name of Facility: Is the home or facility licensed for 16 beds or greater? No Yes B. The individual appears to continue to meet all the standards for protective placement. Yes No, please explain: C. The cu rrent protective placement is the least restrictive environment that is consistent with the individual's needs. Yes No, please explain: D. The individual has a developmental disability and placement is in a nursing home or intermediate facility, and the placement is the most integrated setting appropriate to the individual’s needs. Not Applicable Yes No, please explain: E. An independent eva luation is requested by the individual, the individual’s guardian ad litem or guardian. No Yes, p lease explain: F. The individual or the individual’s guardian requests modification or termination of the protective placement. No Yes , please explain: G. The individual or the individual’s guardian requests or the guardian ad litem recommends that legal counsel be appointed for the individual. No Yes, please explain: H. The individual or the individual’s guardian or the guardian ad litem request s a full due pro cess hearing for the individual. No Yes, please explain: I. Regarding the individual’s attendance at the hearing: it is my opinion that the individual can attend the hearing in court. Report and Recommendation of Guardian ad Litem (Annual Review) Page 2 of 2 Case No. GN -4110, 05/14 Report and Recommendation of Guardian ad Litem (Annual Review of Protective Placement) §55.18(2), W isconsin Statutes. This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 I waive the individual’s attendance after considering the ability of the individual to understand and meaningfully participate, the effect of the individual’s attendance on his/her physical or ps ychological health in relation to the importance of the proceedings and the individual’s expressed desires . I certify the individual is unable to attend for these specific reasons: the individual is unable to attend the hearing in court because of residency in a nursing home or other facility, physical inaccessibility, or a lack of transportation; a nd the individual, advocate counsel, other interested person, or I request that the court hold the hearing in a place where the individual can attend. Specify location requested: 5. I recommend continued protective placement in the facility in which the individual resides at this time. Yes No, please explain: 6. Additional comments: Guardian ad Litem Name Printed or Typed Date